Inflammatory bowel disease in the elderly. Practical treatment guidelines

Colon targeted chitosan-melatonin nanotherapy for preclinical Inflammatory Bowel Disease

Inflammatory Bowel (IBD) is an umbrella term which includes Crohn's Disease (CD) and Ulcerative Colitis (UC). At present, therapies available for management of the UC includes, corticosteroid, immuno-suppressants and antibiotics are used for mild to moderate UC conditions which can cause nephrotoxicity, hepatotoxicity and cardiotoxicity. Hence, a novel therapeutic candidate having potent anti-inflammatory effect is urgently warranted for the management of UC. Melatonin has emerged as a potent anti-inflammatory agent. However, poor solubility limits its therapeutic potential. Therefore, colon targeted Eudragit-S-100 coated chitosan nanoparticles have been demonstrated to improve melatonin therapeutic efficacy. It was found that melatonin loaded chitosan and colon targeted chitosan nanoparticles had promising anti-inflammatory efficacy in terms of NO scavenging activity in an in-vitro LPS challenged macrophages. Also, colon targeted oral chitosan nano-formulation exhibited remarkable protection in an in vivo UC mice model by improving gross pathological parameters, histo-architectural protection, goblet cell depletion, and immune cells infiltration which can be extrapolated to clinical studies.

Inflammatory Bowel Disease is Similar in Patients with Older Onset and Younger Onset

BACKGROUND

As the American population is aging, the number of older people with inflammatory bowel disease is increasing. We used clinical data from the Sinai-Helmsley Alliance for Research Excellence (SHARE), a prospective cohort, to examine disease and treatment differences in older adults.

METHODS

We performed a cross-sectional study assessing demographics and disease behavior by age at diagnosis with univariate, bivariate, and multivariate analyses. "Older-onset" patients were diagnosed after age 60, "younger-onset" patients were diagnosed before age 60 but are older than 60 years, and the remainder were "young."

RESULTS

There were 91 older-onset, 389 younger-onset, and 3431 young patients with Crohn's disease. Older-onset patients had more ileal (37%) and colonic (27%) disease compared with younger-onset and young patients. There were no differences in disease behavior, location, or surgeries between older-onset and young patients with Crohn's disease within 5 years of diagnosis. Older-onset patients with inflammatory disease had a higher odds of being in remission. Young patients reported more anti-tumor necrosis factor and thiopurine use compared with younger-onset and older-onset patients (P < 0.01). There were 98 older-onset, 218 younger-onset, and 1702 young patients with ulcerative colitis. There were no differences in disease extent, activity index, or surgeries. Young patients with ulcerative colitis reported more anti-tumor necrosis factor use (26%) compared with younger-onset patients (17%, P < 0.01).

CONCLUSIONS

Disease behavior or location was not different between younger and older adults with inflammatory bowel disease. Older patients were less likely to be treated with immunosuppression. If older patients have similar disease behavior, less frequent treatment with immunosuppressives may risk suboptimally controlled disease.

Estimation of quality of life in Cypriot patients with inflammatory bowel disease

AIM

To investigate the health-related quality of life (HRQoL) of patients suffering with idiopathic inflammatory bowel disease (IBD).

METHODS

The Greek validated version of the Short Inflammatory Bowel Disease Questionnaire was used for evaluating the quality of life of IBD patients. The questionnaire was distributed to 100 consecutive patients suffering from IBD and presenting for a clinic appointment at the endoscopy unit of Larnaca General Hospital during the period from October to November 2012. The criteria for participating in this study were constituted by the documented diagnosis of either ulcerative colitis (UC) or Crohn's disease (CD) after endoscopy and histologic examination at least 6 months before the study, adult patients (18 years old or older), the capability of verbal communication and the patient's written consent for attending this study. The majority of the questionnaires were completed by a nurse practitioner who specializes in IBD patient care.

RESULTS

Regarding the physical dimension in patients with UC, males scored significantly higher than females (4.2 vs 3.4, P = 0.023). Higher scores were also observed in UC patients younger than 35 or older than 50 years (4.0 and 4.2 vs 3.2, respectively, P = 0.021). The psychological dimension revealed similar results in patients with UC, with males, and older ages scoring higher (5.0 vs 3.0, P = 0.01 and 4.7 vs 2.7, P < 0.5, respectively), whereas regarding CD higher scores were observed in married compared to unmarried (3.83 vs 2.33, P = 0.042). No statistical differences in any parameters in the social dimension were observed. Regarding the treatment of, patients with CD, overall higher scores were observed when treated with biological factors compared to standard therapy in all dimensions but with statistical significant difference in the social dimension (5.00 vs 3.25, P = 0.045).

CONCLUSION

The study reveals a negative impact of IBD on HRQoL. Increased risks are age and gender in patients with UC and family status in patients with CD.

Systematic review with meta-analysis: inflammatory bowel disease in the elderly

BACKGROUND

Elderly patients represent an increasing proportion of the inflammatory bowel disease (IBD) population.

AIM

To critically review available data regarding the care of elderly IBD patients.

METHODS

Bibliographic searches (MEDLINE) up to June 2013.

RESULTS

Approximately 10-15% of cases of IBD are diagnosed in patients aged >60 years, and 10-30% of the IBD population are aged >60 years. In the elderly, IBD is easily confused with other more common diseases, mainly diverticular disease and ischaemic colitis. The clinical features of IBD in older patients are generally similar to those in younger patients. Crohn's disease (CD) in elderly patients is characterised by its predominantly colonic localisation and uncomplicated course. Proctitis and left-sided ulcerative colitis are more common in patients aged >60 years. Infections are associated with age and account for significant mortality in IBD patients. The treatment of IBD in the elderly is generally similar. However, the therapeutic approach in the elderly should be 'start low-go slow'. The benefit of thiopurines in older CD patients remains debatable. Although the indications for anti-tumour necrosis factors in the elderly are generally similar to those for younger patients, lower response and higher adverse events have been reported in the elderly. Surgery in elderly patients does not generally differ. Ileal pouch-anal anastomosis can be successful, provided the patient retains good anal sphincter function.

CONCLUSIONS

Management of the older IBD patient differs from that of younger patients; therefore, conventional practice algorithms may have to be modified to account for advanced age.

Health-related quality of life in patients with inflammatory bowel disease: a single-center experience

BACKGROUND

Inflammatory bowel disease (IBD) has a negative impact on health-related quality of life (HRQoL). The aim of the study was to assess HRQoL of IBD patients in South-Western Greece.

METHODS

89 IBD patients [38 (42.7%) Crohn's disease (CD), 51 (57.3%) ulcerative colitis (UC)] were included. HRQoL was assessed using IBD questionnaire (IBDQ), which tests four health domains: bowel symptoms (BS), systemic symptoms (SS), emotional function (EF) and social function (SF). Total score (TS) ranges from 32 to 224. Disease activity was measured using Crohn's Disease Activity Index (CDAI) (CD), and Truelove and Witts classification (UC). The impact of epidemiological and disease-specific characteristics on IBDQ was studied.

RESULTS

No statistically significant difference was found in all IBDQ scores between UC and CD patients. No correlation was found regarding age, sex, smoking, anemia, disease duration and use of corticosteroids, 5-aminosalicylates or immunosuppressives with HRQoL. The factors found to have a major negative impact on all IBDQ scores was disease severity both in CD and UC, and education on bowel symptoms in CD. On multivariate analysis, only high disease activity had significant effects on total and dimensional scores of IBDQ in UC (TS, P=0.005; BS, P<0.001; SS, P=0.004; EF, P=0.05; SF, P=0.001), whereas in CD, only CDAI (TS, P=0.001; BS, P=0.004; SS, P=0.001; EF, P=0.003; SF, P=0.003) and education (TS, P=0.047; BS, P=0.004; SS, P=0.03) had significant effects.

CONCLUSIONS

IBD patients in remission experience better HRQoL than patients with active disease. Induction of remission should become the mainstay of care regarding improvement in HRQoL.

Age at onset of inflammatory bowel disease and the risk of surgery for non-neoplastic bowel disease

BACKGROUND

There is conflicting data regarding the response to medical and surgical therapy for inflammatory bowel disease with respect to age at disease onset.

AIM

To determine if the age at onset of Crohn's disease and ulcerative colitis is a risk factor for surgery for non-neoplastic bowel disease.

METHODS

This was a case-control study of patients evaluated between 1998 and 2001. Cases had undergone an initial operation for bowel disease. Controls were matched 1:1 for gender, disease subtype, date of first visit (+/-2 years), time from diagnosis prior to first visit (+/-3 years) and duration of follow-up. Association with age, disease extent, smoking history, medication use and co-morbidities vs. case/control status was assessed using multiple variable conditional logistic regression to estimate the odds ratio (OR) and 95% confidence intervals (CI) for undergoing surgery.

RESULTS

Among 132 Crohn's patients, older patients had lower odds for surgery (OR per 5 years, 0.86; 95% CI: 0.75-0.98). The rate of surgery for non-neoplastic bowel disease was not significantly associated with disease distribution, co-morbidities or cigarette smoking. Among 234 ulcerative colitis patients, the rate of surgery was unrelated to age, disease extent, co-morbidities or cigarette smoking,

CONCLUSIONS

For Crohn's disease, but not ulcerative colitis, the risk of surgery for non-neoplastic bowel disease decreases with increasing age at diagnosis, irrespective of disease distribution and history of cigarette smoking.

Inflammatory Bowel Disease After Age 60

New-onset idiopathic inflammatory bowel disease (IBD) is not uncommon among the elderly, although more common are colonic infection, ischemia, or neoplasia, all of which may mimic IBD. Although the clinical presentation of IBD in the elderly often resembles that of younger subjects, atypical manifestations are common and may lead to difficulty in diagnosis. Much progress has been made in both medical and surgical therapy for IBD, but such therapy poses additional challenges in the elderly, who are more likely to experience adverse effects of medications or complications of surgery. The elderly generally have a favorable outcome to both medical and surgical therapy for IBD. Although concern about possible untoward effects of therapy is warranted, treatment should not be withheld because of fear of complications.

Assessing health-related quality of life in patients with inflammatory bowel disease, in Crete, Greece

BACKGROUND

Health Related Quality of Life (HRQoL) is an important outcome measure in Inflammatory Bowel Disease (IBD). The aim of our study was to assess HRQoL in a population of 135 Greek patients with IBD.

METHODS

A cohort of 135 patients with IBD, 81 with ulcerative colitis (UC) and 54 with Crohn's disease (CD) were enrolled in our study. Demographic and disease-related data were recorded. HRQoL was assessed by a disease-specific and a generic questionnaire, IBDQ and SF-36, respectively. Disease activity was assessed by Harvey-Bradshaw Index and the Colitis Activity Index for CD and UC patients, respectively.

RESULTS

Among all variables recorded in our study, only disease activity had a significant effect on HRQoL. Patients with active disease scored significantly lower on both IBDQ and SF-36 when compared to those in remission. Only two among the four IBDQ dimensions, bowel and systemic, had significant ability in distinguishing best patients in remission from those with active disease.

CONCLUSIONS

IBD has a negative impact on HRQoL. Patients with active disease are more impaired than patients in remission. In our population of patients bowel and systemic dimensions had a predominant value in patients' perception of quality of life. Patients in our study using the same instrument scored higher than previously reported.

Crohn's disease in the elderly: clinical features and long-term outcome of 19 Greek patients

AIM

To study the clinical course, prognosis, treatment and follow-up of 19 patients with Crohn's disease aged 60 years or over at the time of onset of symptoms.

PATIENTS AND METHODS

A series of 12 males and 7 females aged 65 +/- 4. 9 and 66. 6 +/- 6 years at the onset of symptoms and the time of diagnosis, respectively (elderly group), were studied. Another group of patients(83 males, 53 females aged 29.8 +/- 12.4 and 32.2 +/- 12.7 at the onset of symptoms and of diagnosis, respectively) served as a control group (young group). Both groups were followed-up for a mean period of 7.2 and 9.8 years, respectively.

RESULTS

The most common site of involvement in the elderly group was the distal ileum (47.4%), followed by large bowel (36.6%) and concurrent large and small bowel involvement (16%). Acute presentation was significantly more common in the older group. Fever and loss of weight were significantly less common in the older group (p<0.05). A higher rate of complications especially acute abdomen, was observed in the elderly group. There were no significant differences in the indication for surgery and type of surgical procedure applied between the two groups. However significantly fewer patients in the elderly group were operated on because of perianal abscess compared to the young group (p<0.05). Follow-up data revealed that elderly patients with Crohn's disease who had been operated upon showed no significant differences in the course of their disease compared to operated young patients.

CONCLUSION

Crohn's disease in elderly persons of Greek origin follows much the same pattern as in other developed countries of the world.

Inflammatory Bowel Disease: Current Pharmacotherapy Issues

Inflammatory bowel disease (IBD) includes two idiopathic syndromes, ulcerative colitis and Crohn's disease. In ulcerative colitis, inflammation is limited to the colonic mucosa and submucosa. Crohn's disease may, however, involve the small intestine, all bowel wall layers, and the upper gastrointestinal tract. Because health-related quality of life is significantly impaired during active disease, pharmaceutical care. is important in patient management. Traditional therapy includes 5-aminosalicylates, corticosteroids, and antimicrobial therapy. In steroid-resistant active disease, immunosuppressants (cyclosporine, azathioprine, 6-mercaptopurine, methotrexate) have a role but possess significant toxicity profiles. Current research focuses on the role of inflammatory mediators in IBD. Investigational therapies include monoclonal antibodies to proinflammatory cytokines, inhibitory cytokines, and anti-CD4 monoclonal antibodies.

Crohn's disease in the elderly: a comparison with young adults

We compare the clinicopathological features of 98 Crohn's disease (CD) patients with initial symptoms at 40 years of age or older (elderly; male n = 56, female n = 42) with those of 347 CD patients with onset of symptoms between the age of 16 and 40 years (young adults; male n = 166, female n = 181). The frequency of presenting symptoms, such as diarrhea, rectal blood loss, and weight loss were comparable in both groups, except for abdominal pain/cramps, which occurred somewhat less frequently in the elderly (59% vs. 71%, p < 0.05). The mean lag time between onset of symptoms and first visit to a general practitioner (GP) was considerably shorter in the elderly than in the young adults (0.2 years vs. 0.6 years, p < 0.001), as was the lag time between GP and referral to a specialist (0.6 years vs. 1.0 years, p < 0.07). Overall, this resulted in a significantly (p < 0.01) shorter time to establish the diagnosis in the elderly (1.8 years vs. 2.7 years). Crohn's disease as correct initial diagnosis was in the elderly less frequently observed than in the young adults (49% vs. 61%, p < 0.05), in contrast to diverticulitis (7.1% vs. 0%) and malignancy (6.1% vs. 0.9%), which were more frequently encountered as incorrect preliminary diagnosis in the elderly (both p < 0.005). The percentage of patients who underwent an abdominal operation was similar in both groups (83% vs. 77%), but the diagnosis CD was in the elderly more frequently established at first operation than in young adults (25% and 12%, p < 0.005). The elderly were found to undergo a bowel operation or resection earlier after onset of symptoms. The development of recurrence after bowel resection, although occurring in a lower percentage of patients, was significantly shorter than in the young adults (3.7 years vs. 5.8 years, p < 0.02). Arthritic extraintestinal manifestations were equally frequent in both groups, but elderly patients had significantly less relatives in the first or second degree affected by CD (3.1% vs. 12%, p < 0.02). We conclude that the diagnosis Crohn's disease is more readily established in elderly patients. Moreover, these patients less frequently have abdominal pain/cramps as a presenting symptom, a shorter time interval between onset of symptoms and first resection, and subsequent recurrence of the disease. In addition, elderly CD patients have less relatives affected by the same disease. Thus, CD in the elderly appears to be characterized by a more rapid development.